Tricare Beneficiary Liability Form (Waiver Of Non-Covered Services)
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1TRICARE Beneficiary Liability Form
(Waiver of Non-Covered Services)
This waiver allows a network (contracted) provider to collect billed charges for services denied as ‘non-covered’ from a TRICARE
beneficiary when the beneficiary has agreed, in writing, to waive his or her balance-billing protection.
I, ________________________________, the TRICARE beneficiary, hereby agree to pay up to the full billed charge(s) for the following
service(s) if such service is subsequently denied as non-covered regardless of the fact the TRICARE program will not make payment:
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
Date: _____________ Service (Code): _________________
[Estimated] Billed Charge: ___________________________
TOTAL [ESTIMATED] BILLED CHARGES: ________________________
Note: This waiver applies to any and all TRICARE non-covered services indicated above rendered by this provider, including,
but not limited to office visits, office procedures, hospital visits, and surgical fees.
I acknowledge that I am signing this statement voluntarily, and that it is not being signed under duress or after the services
have already been provided. I understand that by signing this form, I will be fully responsible for the total billed charge(s) for
any services denied as non-covered and listed above and will pay the provider this amount, regardless of the fact TRICARE
will not make payment. I also understand that it is my choice to have these services provided at a future date and time by
this provider.
TRICARE BENEFICIARY SIGNATURE: _________________________________________________ DATE:___________________
TRICARE BENEFICIARY NAME: (PRINTED)_______________________________________________________________________
SPONSOR SSN: _________________________________________________ RELATIONSHIP TO SPONSOR: ________________
Providers must follow all applicable coding regulations. If an appropriate CPT code exists that covers several procedures rendered, the
provider must use the all-inclusive procedure code and not bill for each procedure separately.
PROVIDER INFORMATION
NAME: _____________________________________________________________________________________________________
ADDRESS: __________________________________________________________________________________________________
CITY: _________________
STATE: __________ ZIP CODE: _________________ PHONE NUMBER: _______________________
This document may contain personally identifiable information, including protected health information. Only those with a need to know should accessor
use this document. Access, use or disclosure of this document or its contents must comply with the MHS Notice of Privacy Practices, the HIPAA Privacy
Rule and the DoD Privacy Program. If you received this document in error, please contact us immediately at 1-877-988-9378.
TRICARE West Region Customer Service: 1-877-988-9378 (WEST)
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